STRATEGY TO IMPROVE PAP SMEAR FOLLOW-UP IN A HIGH RISK UNDERSERVED POPULATION

Northern California Cancer Center, Fremont CA

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Abstract

Rates of follow-up of abnormal Pap smears vary greatly depending on characteristics of women screened and of the screening program, with the lowest rates of follow-up among women at the highest risk of having or developing cervical cancer. Effective strategies are needed to improve the rate of resolution among women typically lost to follow-up. Results from our study of follow-up in a multi-ethnic, under-served, inner city population show that, of 2,167 women screened over 21 months, 147 (6.8%) has an abnormal result of ASCUS or greater. 108 were eligible to be randomized to intervention or control. Despite intensive hospital-based efforts (including reduction of institutional barriers through establishment of a specialized clinic and use of a nurse follow-up coordinator), only 53% of women in the intervention group completed recommended follow-up by 18 months (compared with 14% in the control group), thus resolving their abnormality. The inability to bring women back for diagnostic evaluation and treatment undermines the potential benefits of a Pap smear and the cost-effectiveness of screening. Yet in the absence of data demonstrating the cost-effectiveness of more intensive efforts to pursue follow-up, such activities are unlikely to be adopted in light of diminishing resources in public health institutions. This study is a randomized controlled trial to evaluate the impact and cost- effectiveness of a culturally-tailored community outreach intervention to improve rates of follow-up among 600 women with abnormal Pap smears. Formative research methods will include focus groups, key informant interviews. A conceptual adapted from the Trans-theoretic Model and other behavioral theories guide development of a culturally-tailored Community Health Outreach Worker (CHOW) intervention program. We will compare out intervention to the usual care condition, notification by telephone and letter. Over a six-month follow-up period we will (1) assess the time to the first follow-up appointment, (2) the proportion of women who have a resolution of their Pap smear abnormality, and (3) the time to resolution. Analysis will include a test of the hypothesis that the CHOW intervention is more cost-effective than the usual care.